I voluntarily authorize the health care facility to use or disclose my health information for the purpose of treatment, payment, or other health care operational needs to my physician of choice, my insurance plan, and/or state or federal registries, as needed.
I understand that this authorization will remain its effectivity until I provide written notice of revocation to the health care facility. I do hereby consent and give authority to the health care facility to release information to my employer and process my billing on my behalf whenever applicable.
I have read or have had explained to me the information about influenza and influenza vaccine. I have had an opportunity to discuss the benefits and risks of influenza vaccine with a healthcare provider of my choice before coming here today. I have had a chance to ask questions which were answered to my satisfaction.